DENTAL TREATMENT HISTORY
Date of last visit: ______/______/________ Purpose of visit: ___________________________________________ Last exam: ______/______/________
m Yes m No Antibiotics needed prior to treatment: ________________________________________ Purpose: ________________________________
m Yes m No Nitrous oxide/laughing gas for treatment? Effect: _______________________________________________________________________
m Yes m No Sedation prior to treatment: ________________________________________________ Effect: _________________________________
m Yes m No Stabilization or immobilization for treatment: __________________________________________________________________________
m Yes m No Tolerates dental chair m Yes m No Modifications needed for dental chair: ___________________________________________________
m Yes m No Hx complications following treatment: _______________________________________________________________________________
m Yes m No Removable appliances: _________________________________________________ Wears: m Yes m No Date made: ____/____/_____
Usual response to dental care is:
m normal
Tolerance to touch: m normal
Gag response is:
m cooperative m some resistance m very resistant m not sure
m strong m varies
m avoids m other:__________________________________________________________________
Other: ____________________________________________________________________________________________________
ORAL HEALTH CARE INFORMATION
BRUSHING: _____ times per day: m with reminders
Type of brush:
m manual soft
m with assistance: _____________________________________________________________
m rotary or motorized m surround m adaptations: _________________________________________________
FLOSSING: ____ times per: ___ day ___ week:
m manual
m floss holder
m electric
MOUTHWASH: ____ times per day:
m with reminders m with assistance: ____________________________________
m adaptations: _____________________________________________
m swish m swab m brush
m prescription: __________________________________________________________________________________________________________
m OTC:________________________________________________________________________________________________________________
TOOTHPASTE: ___ OTC ___ with fluoride
___ without fluoride
m prescription: _________________________________________________________________________________________________________
m Yes m No Is oral care at home difficult? How? ________________________________________________________________________________
m Yes m No Do you currently have any pain or other concern regarding your oral health: ___________________________________________________
_____________________________________________________________________________________________________________________
m Yes
m Yes
m Yes
m Yes
m No Is your mouth dry?
m No Do you grind or clench your teeth? m day m night m Yes m No mouthguard
m No Do you participate in sports? Do you wear a mouthguard during sports? m Yes m No
m No Does your drinking water have fluoride?
Are there any transportation concerns we should be aware of? ________________________________________________________
Are there any scheduling or time of day restrictions we should be aware of? A time of day that is preferable (better behavior, etc.)?_________________________
______________________________________________________________________________________________________________________
Is there anything else we should know regarding your oral health/dental treatment care? __________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Name of person completing this form: ___________________________________________________ Relationship: _____________________________
Signature: ____________________________________________________________________________________ Date: ______/______/________